Provider Demographics
NPI:1306891288
Name:HARVARD FAMILY PHYSICIANS P C
Entity type:Organization
Organization Name:HARVARD FAMILY PHYSICIANS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MUCKALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-743-8200
Mailing Address - Street 1:7912 E 31ST CT
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1315
Mailing Address - Country:US
Mailing Address - Phone:918-743-8200
Mailing Address - Fax:918-743-8609
Practice Address - Street 1:7912 E 31ST CT
Practice Address - Street 2:SUITE 220
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-1315
Practice Address - Country:US
Practice Address - Phone:918-743-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26464207Q00000X
OK3713207V00000X
OK24064207V00000X
OK22222207Q00000X
OK21221207Q00000X
OK11366207Q00000X
OK4733208000000X
OK2623111N00000X
OK16314207Q00000X
OK15800207Q00000X
OK15691207Q00000X
OK13762207Q00000X
OK14337207Q00000X
OK17805208000000X
OK14483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100740300AMedicaid
OK100740300AMedicaid
OK=========Medicare ID - Type Unspecified